Assessment of health and science undergraduate students’ knowledge, attitudes, education and training related to antibiotic use and antimicrobial resistance in 27 EU/EEA universities
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Introduction: Antimicrobial resistance (AMR) is a complicated public health challenge. The aim of this study was to obtain a baseline assessment of the capacity, opportunity, and motivation of undergraduate health and science students across European countries to evaluate behaviour and education methods on antibiotic use, resistance, stewardship. Methods: A 43 item cross-sectional multilingual survey of healthcare practitioners and undergraduates studying dentistry, medicine, nursing, pharmacy, and science students in 30 EU/EEA countries was conducted in 2018. Of the 43 questions, a sub-set of 33 questions directly relevant to students were selected for analysis. Results: A total of 1222 students from 27 EU/EEA countries participated in the survey with the majority reading medicine (50%, 379/760). The mean score across seven knowledge questions was 6.04 (out of 7), with a standard deviation of 1.14. Knowledge scores differed by degree being read and was higher for students in the later years of their degree program. Knowledge was significantly higher in those who had received training and assessment or had practical experience of prudent antibiotic use and infection management. Most students had not heard about AMR awareness campaigns and felt they do not have a key role in addressing AMR. Conclusion: Although health and science students achieved good overall knowledge on questions relating to antibiotic use and AMR, many respondents showed a lack of awareness regarding their role in tackling AMR. Designing more effective targeted educational interventions such as curricula development and interprofessional education and training could be beneficial to target antibiotic use and AMR.
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Comments to Author
This is an interesting paper, addressing an important area - awareness/action for students regarding AMR. The survey appears to be tied to a previous survey whose findings have already been published. However, the subjects who completed this survey represent a different population, specifically students in relevant areas of study. It is really commendable that such a wide geographical and linguistic reach has been possible. I would perhaps like to see some critical comment on reach and success of attracting participants. Also more exploration of how the education aspects might be implemented across nations - the difficulties are mentioned only briefly in the strengths and limitations section. I have a few comments for consideration: Abstract. This is not too clear. line 53 should this be a 'sample of ' …
Comments to Author
This is an interesting paper, addressing an important area - awareness/action for students regarding AMR. The survey appears to be tied to a previous survey whose findings have already been published. However, the subjects who completed this survey represent a different population, specifically students in relevant areas of study. It is really commendable that such a wide geographical and linguistic reach has been possible. I would perhaps like to see some critical comment on reach and success of attracting participants. Also more exploration of how the education aspects might be implemented across nations - the difficulties are mentioned only briefly in the strengths and limitations section. I have a few comments for consideration: Abstract. This is not too clear. line 53 should this be a 'sample of ' undergraduate...students. Line 54, should there be a comma after 'behaviour' and 'and' before stewardship? The sentence is not too clear. line 56 delete word 'students'. Line 60 the data provided for the 'majority reading medicine' : if the total is 1222, how is the majority 50% (not a majority) and the number given 379/760? line 70 'interventions FOR THESE STUDENTS such as .. Introduction is clear and relevant. Line 89 full stop after 'consumption. Line 117 'the same survey was also completed by healthcare professionals and the results for healthcare workers has been published'. This is not clear: are the subjects different?. Contine 'TheSE results..... Do you need to mention world antiMICROBIAL awareness day as well? Methods. Line 129 'as part of evaluating EAAD.... Should this be 'the success/impact/effectiveness of the EAAD campaign' or suchlike?. ...continuing 'a questionnaire for A survey..... Line 139 explain what is COM-B. Line 142. How was the survey promoted? To members by mailing list? What was the total reach possible and thence the success of the call? Is it possible to comment on this? 148 what is a self-administered survey? Is it one that is completed independently? line 179 a reference for the REC assessment tool? Line 184, full stop after 'questionnaire'. Results. I do not see why a full reference for a previous papers is included in full in almost every figure/table. I found the comments on training and teaching methods interesting. If students thought role play was the least effective teaching method, is this just some sort of student prejudice? The links made to the education literature regarding education methods/active and passive learning etc. in the section on this in the discussion (which erroneously refers to table 7?) are useful, and could perhaps be expanded upon (the difficulties of implementing effective methods across countries). The comments made are based only on the perceptions of the students rather than on the literature in the area. Strengths and limitations section is useful. How do you know that students might use online resource. Does this matter if the knowledge emerges as a result? What is convenience samPling? Problems of variation in 'cell sizes'? Please also check use of curricula/curriculums for consistency. Conclusion: 'more than half of students WHO RESPONDED TO THE SURVEY' What is AMU? Otherwise, thank you for the work, which encompasses a large study and generates some interesting observations and potential for future research and implementation of literacy/stewardship work.
Please rate the manuscript for methodological rigour
Good
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
General comments Thank you for the chance to review this paper, I have added my comments below following the structure from Access Microbiology. I hope these enhance the quality of the paper. I would like to start by saying that surveys such as these are fairly common within healthcare courses, but one area that sets this particular survey apart is the scale across several European countries, there are important gaps and caveats however, which do need exploring and addressing and are outlined here: Methodological rigour, reproducibility and availability of underlying data The method is via a survey translated and distributed to students in multiple European countries and studying different disciplines. The survey appears to be extremely long (33 questions) which may partly account for the number of …
Comments to Author
General comments Thank you for the chance to review this paper, I have added my comments below following the structure from Access Microbiology. I hope these enhance the quality of the paper. I would like to start by saying that surveys such as these are fairly common within healthcare courses, but one area that sets this particular survey apart is the scale across several European countries, there are important gaps and caveats however, which do need exploring and addressing and are outlined here: Methodological rigour, reproducibility and availability of underlying data The method is via a survey translated and distributed to students in multiple European countries and studying different disciplines. The survey appears to be extremely long (33 questions) which may partly account for the number of missing responses. An important distinction that should be made is that some of the courses surveyed may not be future prescribers which may also account for their lack of knowledge (because they have not received clinical/communication skill training in these areas) and this should be commented upon throughout the manuscript. There is a lot of raw data present and the results presented are quite descriptive. Looking to enhance the analysis of this would be something to consider. From a reader perspective, I hoped for more in the way of actionable points to take away from the paper. Line 125 - please specify (if possible) which science undergraduate students were surveyed. One aspect I felt was missing was a comparison with the previously published survey in 2021 (ref 7). Whilst I appreciate this survey looks at students, supplementary table 3 corresponds to table 3 in this 2021 paper - are there trends the authors can identify? Are there other trends amongst other published works that the authors can link to? There were some interesting findings reported here which could be explored via open text or interviews e.g perceptions of teaching and training. Again, I felt this was a fairly obvious thing to consider or comment upon in future work/discussion/conclusion. Presentation of results Given the size of the survey, I found that it would be helpful to tag questions within the tables and manuscript with questions within the survey itself as it was quite confusing going back and forward to the supplemental data. For example, table 1 is displayed in a confusing manner, listing question 14, 16, 15, then a question I cannot find in the survey, then question 17. Within the text itself, I would recommend that the authors double check their percentages and where used, report these accurately. For example, from lines 235 - 249, I found this whole section very difficult to read, partly because the numbers reported did not correspond to the table underneath. Line 238 - you say 'approximately 80% of dentistry and pharmacy students' - please report this as 81% and 79% respectively. Later (line 243 and 244), you report percentages of 85% and 84% - but 35/43 is 81% and 122/154 is 79% (both these numbers correspond to the data in table 1). Whilst I understand that you are trying to report some generalisable results, this is quite confusing. Please check all these percentages throughout for accuracy. Table 2 - I would like a comment on some of the questions asked. For example, Question 18 I find quite difficult to understand and the question itself would have been enhanced by specifying 'antibiotics in wastewater in the environment' - such a high 'unsure' response rate to this question may be explained by students failing to understand the question rather than specifically lacking knowledge of antibiotics per se. this is a methodological limitation more generally. Figure 2 - please add a comment that not all of the students surveyed will be prescribers which could also explain some of the responses. Table 3: again, please tag the questions in the table to the questions in the survey. I was slightly unsure whether this data refers to a Likert scale or a binary 'yes' 'no' response. I would disagree that these data refer to knowledge, but rather perceptions of knowledge i.e. a student may think they have knowledge in an area, but objective assessment may reveal otherwise. This would be a good place to link to the literature too. Could the data in table 3 be broken down further - might it be explained that students in stage 1 or 2 may not yet have received training on this? Could it be that within crowded healthcare curricula, more needs to be done to enhance the visibility of these topics amongst other areas competing for the attention of the student? How the style and organization of the paper communicates and represents key findings The paper is presented in a logical format. It would benefit from further check to enhance the flow of the article and readability e.g. line 80 'the nature of microorganism' was quite confusing. Aside from the percentages mentioned above, please check that the tables in text correspond to the tables and figures presented. Discussion A few points to make: the increase of perception of knowledge increases from year 1 - 5 (again, not all bioscience or other courses are 5 years long, so this needs a comment) is unsurprising. It does suggest that learning is occurring whether students perceive they have enough formal teaching sessions on this or not? Again, I think that there needs to be a distinction between teaching and learning. I would be curious to know what other materials students are using (under the 'opportunity of getting antibiotic information'.) Educational intervention on antibiotic use Again, some of these comparisons are unfair as a 'science' student may not have received clinical skills etc because they are not training for a patient facing role. Also in this section, you refer to table 7, but I think you are referring to table 3? Could the authors elaborate more on 'vignette-based clinical scenario training'. Since this came top of interventions that students felt were the most useful, what does this mean? Is it referring to Case based/Problem based learning scenarios or other? It was interesting that peer teaching was perceived as 'passive' despite a large amount of literature that supports the use of peer led teaching and could be quite active in terms of what occurs. Could the authors say more here? Are there ways that these methods could be combined, for example, using large scale teaching and vignettes? I think this section would benefit with some recommendations based on the results found which would make it more actionable by the reader. Literature analysis As mentioned I think there are some obvious comparisons with the 2021 paper and parallel questions that they authors asked as part of that study which would enhance this paper. I think much more could have been done to compare with the 2015 Pulcini paper to look at trends this paper identifies, compared with the data presented here to identify progress made since that time. I would cautiously agree that more time needs to be dedicated to AMR and AMS teaching and learning, but how do we do that in a crowded environment and the perception that health care students have regarding teaching on any topic (rarely, if ever, is a topic deemed to have enough teaching time attached to it). Other comment A very minor one, but please check the references as there are lots of minor formatting errors here
Please rate the manuscript for methodological rigour
Satisfactory
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes